Introduction
Breast cancer is the most common cancer in women of all ages. About 1-3 million women are diagnosed with breast cancer in their lifetime worldwide. It is the third leading cause of death in women [1]. Screening is one of the ways for early diagnosis to reduce the mortality rate [4]. Increasing health literacy is among the most important factors in encouraging women with breast cancer to undergo screening [6]. However, high awareness of cancer or cancer literacy does not always end in positive results; in some people, who may have already witnessed the cancer of people around them, knowing more about the symptoms of cancer can increase anxiety [10]. Anxiety plays an important role in taking preventive measures, especially avoiding screening for breast cancer [14]. Maheu et al. [15] introduced the fear of cancer as a multidimensional construct, including stimuli, feelings, thoughts, physiological reactions, and coping strategies against cancer. Lee et al. [17] stated that high levels of concern about breast cancer can motivate women to have mammography. Popa-Velea et al. [26] showed that psychological resilience affects the perception of quality of life in cancer patients. Psychological resilience refers to the ability to resist changes [20] or a positive capacity to adapt to stress [21]. People with high psychological resilience against stress find positive meaning and can face problems and unfortunate situations more easily [22]. This research aims to model the relationship of breast cancer screening with health anxiety and cancer literacy, mediated by psychological resilience.

Methods
This is a descriptive correlational study. The study population consists of all women over 40 years of age referred to the mammography clinics of specialized and super-specialized hospitals in Rasht, Iran from March to July 2022. Of these, 300 were selected by a convenience sampling method. The data collection tools included: 
Mammography and breast cancer screening questionnaire: It was designed by Nourizadeh et al. [4],  having 34 items rated on a 4-point Likert from 1 (insufficient) to 4 (completely sufficient). Higher scores indicate unwillingness to undergo breast cancer screening. Nourizadeh et al. reported the Cronbach’s alpha coefficient for the whole questionnaire as 0.78, and the test-retest reliability coefficient (with a two-week interval) was 0.91.  In the current study, Cronbach’s alpha of the whole questionnaire was calculated as 0.79.
Health anxiety inventory: It was developed by Salkovskis et al. [31], having 18 items rated from 0 to 3, with a high score indicating higher health anxiety. The test-retest reliability of this questionnaire is 0.90 and its Cronbach’s alpha coefficient ranges from 0.70 to 0.82 [31]. For the Persian version, Nargesi [32] reported a Cronbach’s alpha of 0.87. In the present study, Cronbach’s alpha of the Persian version was calculated as 0.83.
Breast cancer awareness scale: It was designed by Momayyezi & Fallahzadeh [5], having 30 items rated on a 3-point Likert scale as 1 (no), 2 (no idea), and 3 (yes). Cronbach’s alpha coefficient for all dimensions is higher than 0.80, and the intraclass correlation coefficient is in the range of 0.84-0.95. In the present study, the Cronbach’s alpha of this questionnaire was calculated as 0.82.
Connor-Davidson resilience scale: It was developed by Conner & Davidson [33], having 25 items rated on a 5-point Likert scale from 0 (not true at all) to 4 (true nearly all of the time). A score less than 50 indicates lower psychological resilience while a score greater than 50 indicates greater psychological resilience. The Cronbach’s alpha coefficient of this tool is 0.89 and the factor analysis coefficient is equal to 0.87 [33]. Mohammadi et al. [34] confirmed the Persian version’s construct validity and internal consistency and reported a Cronbach’s alpha of 0.89.

Results
Mean scores of breast cancer screening, health anxiety, cancer literacy, and psychological resilience were 77.16±8.08, 33.67±5.65, 67.54±6.56, and 87.21±12.10, respectively. The results of the Kolmogorov-Smirnov test showed that all the studied variables had a normal distribution (P>0.05). The values of GFI, Normed Fit Index, incremental fit index, comparative fit index, and Tucker–Lewis index were obtained as 0.99, 0.97, 0.99, 0.98, and 0.99, respectively, and the root mean square error of approximation was equal to 0.056, indicating the appropriate fit of the model. 
The path coefficient between health anxiety and breast cancer screening was 0.38; between health anxiety and psychological resilience, 0.25; between health anxiety and cancer literacy, -0.22; between cancer literacy and breast cancer screening, -0.11; between cancer literacy and psychological resilience, -0.17; and between psychological resilience and breast cancer screening, 0.25. Also, cancer literacy had a significant indirect relationship with breast cancer screening through psychological resilience. Health anxiety also had a significant indirect relationship with breast cancer screening through psychological resilience (Figure 1).
Conclusions
The results showed that health anxiety had a positive direct relationship with breast cancer screening, which is consistent with the findings of Park and Lim [16]. Women with high anxiety about their health are more likely to undergo breast cancer screenings. Cancer literacy had a direct negative relationship with breast cancer screening, which is inconsistent with the findings of Lewis et al. [7] but consistent with the findings of Ilic and Misso [11]. Psychological resilience had a direct positive relationship with breast cancer screening. These results are in line with the findings of Edward et al. [25] and Popa-Vilia et al. [26]. Many women may not have the ability to face the screening results due to their low resilience and tolerance and refuse to do it. Cancer literacy had a significant indirect relationship with breast cancer screening through psychological resilience. Thus, an increase in health literacy leads to a decrease in psychological resilience. Health anxiety also had an indirect relationship with breast cancer screening through psychological resilience. Psychological resilience reduces negative emotions and worries and increases the adaptation ability in a person; by creating a sense of empowerment, it leads to changes in health-related behavior such as screening [40].
Overall, it can be concluded that health anxiety is related to increased breast cancer screening, but health literacy is related to decreased breast cancer screening. Psychological resilience can mediate the relationship of health anxiety and health literacy with breast cancer screenings.

Ethical Considerations
Compliance with ethical guidelines
Ethical approval was obtained from the University of Mohaghegh Ardabili (Code: IR.UMA.REC.1401.004).

Funding
This study was funded by the University of Mohaghegh Ardabili.

Authors contributions
Conceptualization: Matine Ebadi and Sajjad Basharpoor; investigation: Arefe Mohamadnezhad Devin and Matine Ebadi; Editing and review: Sajjad Basharpoor and Arefe Mohamadnezhad Devin.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the officials and staff of Negah Imaging Center and Al-Zahra Hospital in Rasht and all the women participated in this research.


References

1. Jassim GA, Doherty S, Whitford DL, Khashan AS. Psychological interventions for women with non-metastatic breast cancer. Cochrane Database of Systematic Reviews. 2023; 1(1):CD008729.[DOI:10.1002/14651858.CD008729.pub3] [PMID]
2. Vahabi M. Breast cancer screening methods: A review of the evidence. Health Care for Women International. 2003; 24(9):773-93. (Persian) [DOI:10.1080/07399330390229957] [PMID]
3. Xie T, Sun W, Chen D, Liu N, Wang X, Zhang W. Self-efficacy and its influencing factors of breast cancer screening for female college students in China. Journal of Obstetrics and Gynaecology Research. 2019; 45(5):1026-34. [DOI:10.1111/jog.13931] [PMID]
4. Nourizadeh R, Mogaddam Tabrizi F, Vahdati S. [Development and Psychometric Testing of an Instrument to Measure Determinants of Mammography (Persian)]. Payesh. 2017; 16(5):647-58. [Link]
5. Momayyezi M, Fallahzadeh H. Construction and validation of breast cancer awareness scale in Iranian women. Journal of Caring Sciences. 2020; 9(3):140-7.‏   [DOI:10.34172/jcs.2020.021] [PMID]
6. Saei Ghare Naz M, Mohaddesi H, Abed M, Darooneh T, Salmani F, Rashidi-Fakari F, et al. [Breast cancer screening practice and its relationship with breast cancer screening belief in women referred to health centers affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran (Persian)].  Journal of Isfahan Medical School. 2018; 36(500):1234-41. [DOI:10.22122/jims.v36i500.10790]
7. Lewis JA, Chen H, Weaver KE, Spalluto LB, Sandler KL, Horn L, et al. Low provider knowledge is associated with less evidence-based lung cancer screening. Journal of The National Comprehensive Cancer Network. 2019; 17(4):339-46.‏ [DOI:10.6004/jnccn.2018.7101] [PMID]
8. Almadi MA, Alghamdi F. The gap between knowledge and undergoing colorectal cancer screening using the Health Belief Model: A national survey. Saudi Journal of Gastroenterology: Official Journal of the Saudi Gastroenterology Association. 2019; 25(1):27-39.‏  [DOI:10.4103/sjg.SJG_455_18] [PMID]
9. Jelveh M, Vafaee Najar A, Rahbari S, Daghighbin E. [Evaluation of knowledge, attitude, and practice of women on breast cancer and its screening: A step towards health reform (Persian)]. Navidno. 2020; 23(76):52-62. [Link]
10. Nakata H, Halbach S, Geiser F, Stock S, Kowalski C, Enders A, et al. Health literacy, mental disorders and fear of progression and their association with a need for psycho-oncological care over the course of a breast cancer treatment. Psychology, Health & Medicine. 2021; 26(7):818-31. [DOI:10.1080/13548506.2020.1772987] [PMID]
11. Ilic D,  Misso ML. Screening for testicular cancer. Cochrane Database of Systematic Reviews. 2011; 5(2):35-47.‏ [Link]
12. Saab MM, Landers M, Hegarty J. Testicular cancer awareness and screening practices: A systematic review.  Oncology Nursing Forum. 2016; 43(1):8-23.‏  [DOI:10.1188/16.ONF.E8-E23] [PMID]
13. Lee HY, Lee MH, Jang YJ, Lee K. Breast cancer screening disparity among Korean American Immigrant Women in Midwest.Asian Pacific Journal of Cancer Prevention. 2017; 18(10):2663-67. [PMID] 

14. Hay JL, McCaul KD, Magnan RE. “Does worry about breast cancer predict screening behaviors? A meta- analysis of the prospective evidence. Preventive Medicine. 2006; 42(6):401-8.  [DOI:10.1016/j.ypmed.2006.03.002] [PMID]
15. Maheu C, Singh M, Tock WL, Eyrenci A, Galica J, Hébert M,  et al. Fear of cancer recurrence, health anxiety, worry, and uncertainty: A scoping review about their conceptualization and measurement within breast cancer survivorship research. Frontiers in Psychology. 2021; 12:644932. [DOI:10.3389/fpsyg.2021.644932] [PMID]
16. Park SY, Lim JW. Cognitive behavioral therapy for reducing fear of cancer recurrence (FCR) among breast cancer survivors: A systematic review of the literature. BMC Cancer. 2022; 22(1):217.[DOI:10.1186/s12885-021-08909-y] [PMID]
17. Lee JM, Lowry KP, Cott Chubiz JE, Swan JS, Motazedi T, Halpern EF, et al. Breast cancer risk, worry, and anxiety: Effect on patient perceptions of false-positive screening results. The Breast. 2020; 50:104-12. [DOI:10.1016/j.breast.2020.02.004] [PMID]
18. Sheykhan R, Sepahvandi M, Ghazanfari F. [Role of breast cancer worry and mammography self efficacy in intention and mammography screening behavior (Persian)]. Health Psychology. 2019; 8(31):79-90. [DOI:10.30473/hpj.2019.41063.4053]
19. Dooley LN, Slavich GM, Moreno PI, Bower JE. Strength through adversity: Moderate lifetime stress exposure is associated with psychological resilience in breast cancer survivors. Stress and Health. 2017; 33(5):549-57. [DOI:10.1002/smi.2739] [PMID]
20. Gan Y, Li L, Zhang L, Yan S, Gao C, Hu S, et al. Association between shift work and risk of prostate cancer: A systematic review and meta-analysis of observational studies. Carcinogenesis. 2018; 39(2):87-97.‏  [DOI:10.1093/carcin/bgx129] [PMID]
21. Panpakdee C, Limnirankul B. Indicators for assessing social-ecological resilience: A case study of organic rice production in northern Thailand. Kasetsart Journal of Social Sciences. 2018; 39(3):414-21. [DOI:10.1016/j.kjss.2017.07.003]
22. Akhteh M, Alipor A, Sarifi Saki S.  [Effectiveness of stress management training in reducing anxiety and meta-worry of women who had abortion several times (Persian)]. Health Psychology. 2014; 3(11):120-9. [Link]
23. Farahbakhsh S, Mehri Nejad SA, Moazedian A. [Predicting self-efficacy of women with breast cancer based on quality of life, religious orientation, resilience, death anxiety, psychological hardiness and perceived social support (Persian)]. Iranian Journal of Health Psychology. 2019; 2(1):65-78. [Link] 
24. Heidarian A, Zahrakar K, Mohsenzade F. [The effectiveness of mindfulness training on reducing rumination and enhancing resilience in female patients with breast cancer: A randomized trial (Persian)]. Iranian Journal of Breast Diseases. 2016; 9(2):52-9. [Link] 
25. Edward KL, Chipman M, Giandinoto JA, Robinson K. Quality of life and personal resilience in the first two years after breast cancer diagnosis: Systematic integrative review. British Journal of Nursing. 2019; 28(10):S4-14.‏ [DOI:10.12968/bjon.2019.28.10.S4] [PMID]
26. Popa-Velea O, Diaconescu L, Jidveian Popescu M, Truţescu C. Resilience and active coping style: Effects on the self-reported quality of life in cancer patients. The International Journal of Psychiatry in Medicine. 2017; 52(2):124-36.‏ [DOI:10.1177/0091217417720895] [PMID]
27. Freire de Medeiros CM, Arantes EP, Tajra RD, Santiago HR, Carvalho AF, Libório AB. Resilience, religiosity and treatment adherence in hemodialysis patients: A prospective study. Psychology, Health & Medicine. 2017; 22(5):570-7. [DOI:10.1080/13548506.2016.1191658] [PMID]
28. Jackson KO. Relationships between resilience indicators and engagement in disease prevention behavior among adults in the Health and Retirement Study [MA thesis]. Atlanta: Rollins School of Public Health; 2017. [Link]
29. Tazhibi M, Babazade Sh, Fazeli Z, Tabatabai M, Rezai P, Faghihi M. [The study of age trend of breast cancer patients referred to radiotherapy and oncologydepartment of Isfahan hospitals after screening and awareness (Persian)]. Iranian Journal of Breast Diseases. 2011; 4(3):47-51. [Link]
30. Loehlin JC. Latent Variable Models: An introduction to factor. Path and Structional Analysis. New York: Psychology Press; 2003.  [Link]
31. Salkovskis PM, Rimes KA, Warwick HM, Clark DM. The health anxiety inventory: Development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine. 2002; 32(5):843-53. [DOI:10.1017/S0033291702005822] [PMID]
32. Nargesi F. [Examining dysfunctional beliefs, personality traits and history of serious illness in teachers with and without health in Andimshek city (Persian)] [MA thesis]. Ahvaz: Shahid Chamran University of Ahvaz; 2011. [Link]
33. Connor KM, Davidson JR. Development of a new resilience scale: The Conner-Davidson Resilience Scale (CD-RISC). Journal of Depression and Anxiety. 2003; 18(9):76-82.  [DOI:10.1002/da.10113] [PMID]
34. Mohammadi M, Jazayeri AR, Rafie AH, Joukar B, Pourshahbaz A. [Resilience factors in individuals at risk for substance abuse(Persian)]. Journal of Psychology (Tabriz University). 2006; 1(2-3):203-24. [Link]
35. Loving VA, Aminololama-Shakeri S, Leung JWT. Anxiety and its association with screening mammography. Journal of Breast Imaging. 2021; 3(3):266-72.  [DOI:10.1093/jbi/wbab024] [PMID]
36. Emami L, Ghahramanian A, Rahmani A, Mirza Aghazadeh A, Onyeka TC, Nabighadim A. Beliefs, fear and awareness of women about breast cancer: Effects on mammography screening practices. Nursing Open. 2021; 8(2):890-9. [DOI:10.1002/nop2.696] [PMID]
37. Schifferdecker KE, Tosteson ANA, Kaplan C, Kerlikowske K, Buist DSM, Henderson LM, et al. Knowledge and perception of breast density, screening mammography, and supplemental screening: in search of “informed”. Journal of General Internal Medicine. 2020; 35(6):1654-660. [DOI:10.1007/s11606-019-05560-z] [PMID]
38. Spurlock WR, Cullins LS. Cancer fatalism and breast cancer screening in African American women. ABNF Journal. 2006; 17(1):38-43. [PMID] 
39. Noori K, Sahraee P, Keshavarz Mohammadi N. [Barriers to participation of breast cancer patients’ relatives in mammographic screening (Persian)]. Iranian Journal of Breast Diseases. 2021; 14(2):26-40. [DOI:10.30699/ijbd.14.2.26]

40. Shoakazemi M,  Momeni M. [Comparative study of independent and capable women with breast cancer and healthy women (Persian)]. Quarterly Journal of Breast Diseases. 2012; 1(3):45-53. [Link]