BMC Public Health 2006, 6:211 http://www.biomedcentral.com/1471-2458/6/211 neutral/negative, i.e. 61 versus 16) for the purposes of logistic regression. The overall affective tone of women's responses was not affected by maternal or infant age at time of screening, or by EPDS score (ORs 1.02, 0.99 and 1.01 respectively, p > 0.05 in all three cases). Only the reported level of comfort (Fig 1) was related to whether women's commentary on screening with the EPDS was itself neutral/negative versus positive (OR = 2.67, CI 1.28–5.55). Thus, the higher a woman's reported comfort level, the more likely a positive tone in her written com- ments on completing the EPDS. Discussion Increasingly, the utility and cost-effectiveness of health interventions, including screening programs, is assessed through direct modelling of the costs (financial expenses, risks of harm etc) and the benefits (functions of screening tool accuracy, disease prevalence and the scope for disease prevention and treatment) of competing strategies [21- 23]. The results of such models must still be judged in relation to so-called 'second-stage filter criteria' such as feasibility of implementation and the tolerability/accept- ability of the procedure [24]. After all, even if a screening program is highly cost effective, there is no point in imple- menting procedures that are intolerable to patients. This study provides quantitative data on the acceptability of the EPDS, a widespread and important health screening tool both in Australia and worldwide, in a sample that includes substantial numbers of clinically depressed women. As in a similar study with smaller numbers of depressed perinatal women [15] we found that the large majority rate their experience of being screened with the EPDS as comfortable. We have shown this result to hold true for women with elevated EPDS scores, for women with DSM-IV diagnoses of depression and for women sur- veyed by post, telephoned at home or interviewed face-to- face by a psychologist. Women with higher EPDS scores did tend to rate the EPDS as less acceptable (i.e. less com- fortable), as one might expect intuitively, but the strength of this effect was relatively small. Furthermore, 462/479 (96.5%) respondents indicated that universal screening was a "good idea" and this opinion was unrelated to both EPDS score and to comfort level:- even women who did experience discomfort in screening believed that such screening was useful. This remained true even among those women who had formal DSM-IV diagnoses of depression. These are novel findings and may well be of value for professionals involved in conducting and evalu- ating perinatal depression screening. Nonetheless, the results raise some questions in our minds. First, could the EPDS itself be revised somehow to increase its acceptabil- ity further? Second, are there ways of administering the EPDS that help to minimise and deal with the discomfort reported by some women? How can this be done in ethi- cal balance with the majority opinion that screening all new mothers is desirable? When given the chance to respond in open-ended fash- ion, the most frequent of women's responses was that screening with the EDPS had been "fine", "easy", or "good". The affective tone of these responses was apparently more likely to be positive among those women surveyed by tel- ephone and we are unsure why this should be the case. As only about 4% of respondents were surveyed by tele- phone this is unlikely to have affected the current results, but should be borne in mind in any future survey of women's experiences of the EPDS. Although our results indicate that in this sample, the level of acceptability for perinatal depression screening is relatively high, further studies will help to fill what is still a sizeable gap in the evidence base. Whilst our study had a number of strengths including a relatively large sample size, the high representation of depressed women and the attempt to quantify acceptabil- ity directly, the study also had a number of limitations. First, given the relative novelty of measuring and analys- ing acceptability for the EPDS we proceeded by asking questions that seemed sensible and pertinent to us after reviewing how acceptability is measured and analysed for other screening procedures. Alternative methods of quan- tification could be explored and although we have not provided an in-depth, qualitative theme analysis of women's experiences, such an endeavour may prove valu- able. In the current study we made only a simple assess- ment of responses in a sub-sample of women's open- ended responses. Second, we surveyed only women who had been screened via Maternal & Child Health Nurses. However, the EPDS is used in a wide range of primary health care settings and its acceptability is yet to be quan- tified fully in these other scenarios. For example, Shake- speare et al [14] found a low rate of acceptability among a smaller sample screened in General Practice settings in the U.K., yet we ourselves find good acceptability among Aus- tralian women in Child Health Centres. How then might acceptability vary in other countries, cultures and care set- tings? Does the presence and support of a Maternal and Child Health Nurse during screening enhance its accepta- bility? Next, on average we surveyed women about one year after their screening and this may or may not be the best time to have measured acceptability. Partly as a con- sequence of this timing, we had a postal response rate of just above 50% and it remains unknown if a self-selection bias could have affected our results, although given the relatively weak relationships of acceptability and opin- ions on screening with timing and EPDS score among the respondents we expect the broad shape of our findings to be quite robust. Finally, we were unable to collect broad demographic data in this survey and so the analysis could Page 6 of 8 (page number not for citation purposes)