Introduction
The publication of guidelines is unlikely to change clinical behaviour without further dissemination and implementation activities. There remains uncertainty about how best to disseminate and implement guidelines, especially in the community pharmacy setting.

Vulvovaginal candidiasis (VVC) and its treatment with over-the-counter anti-fungals fulfils criteria for guideline development. The purpose of this study was to compare the effectiveness and efficiency of two educational strategies - educational outreach (EO) visits and continuing professional development (CPD) � to enhance the adoption of guideline recommendations for the treatment of VVC in the community pharmacy setting.

Method
A group of 12 local stake-holders and experts developed guidelines for the treatment of VVC. The guidelines were derived from the results of comprehensive and systematic literature reviews. A cluster RCT using a 2 x 2 factorial design was conducted to evaluate the two educational strategies. Community pharmacies in Grampian, Scotland were recruited and randomised to four groups:

1. Control � no intervention
2. EO � one EO visit
3. CPD � attendance at one CPD meeting
4. EO & CPD � one EO visit and attendance at one CPD meeting

The purpose of the EO visits and CPD meetings was to promote the guideline recommendations and to encourage their adoption into practice. All participating pharmacies received the guideline materials.

The identification and follow-up of patients in community pharmacy is difficult. Simulated patients are role-playing actors and may provide a solution to this problem. Ten local amateur actors were recruited and trained by experts in role-play. Seven scenarios were devised; the outcome of the scenarios was either the sale or no-sale of an appropriate anti-fungal. Each actor visited specific pharmacies using different scenarios throughout the trial. Each pharmacy received two baseline and five follow-up visits. Pharmacy staff were aware that simulated patients were being used, however, they did not know when, nor the number of visits, that would be made. The primary outcome measure for the trial was the number of appropriate outcomes post-intervention. This was derived from assessment form data completed by the actors following each visit.

Results
Sixty pharmacies were randomised and received the guidelines in April 1999. Of the 30 pharmacies in the EO groups, 29 (97%) received an EO visit. Of the 30 pharmacies in the CPD groups, 24 (80%) were represented by at least one member of staff at a CPD meeting.

Of the 120 scheduled baseline visits from simulated patients, 119 were completed. Of the 300 scheduled follow-up visits, 295 (98%) were completed. Of the 414 completed visits, four (1%) were detected by pharmacy staff. The analysis of the appropriateness data is underway and the results will be available for presentation in April 2001.

Conclusion
This is the first RCT in the UK to use simulated patients to evaluate the effectiveness and efficiency of guideline implementation strategies in the community pharmacy setting. The results of this study will inform the future development of educational strategies for community pharmacists and their staff.