'Responsive Dialogues', an engagement framework for antimicrobial resistance: a cross-country qualitative evaluation in Thailand and Malawi.

Antimicrobial resistance (AMR) is a global health crisis requiring multisectoral responses that extend beyond biomedical interventions. Participatory approaches can ensure that policies and practices reflect community realities, yet evidence from low- and middle-income countries (LMICs) remains limited. To examine how the Responsive Dialogues (RD) framework was implemented in Malawi and Thailand, and to identify lessons on adapting participatory methods for AMR engagement, managing power dynamics, overcoming structural barriers, and supporting policy uptake. This cross-country evaluation applied the RD toolkit developed by the Wellcome Trust, which included three phases: groundwork, community conversations, and post-conversation sharing. Both countries followed this framework but adapted it to their social and political contexts. Data included field observations, facilitator reflections, participant feedback, and analysis of policy outcomes. Four themes emerged across both sites. First, adaptation was engagement process which shaped by trust, flexibility, and cultural sensitivity. Second, entrenched hierarchies influenced participation; strategies such as stakeholder briefings, ground rules, and rotating leadership roles helped mitigate imbalances, while in Malawi, village leaders' authority supported antibiotic regulation. Third, although Malawi's RD recommendations informed its revised National Action Plan on AMR, Thailand's community generated ideas were less visible in the national strategy, underscoring persistent gaps between local insights and high-level policy. Finally, reflective practice strengthened iterative learning and inclusivity. Overall, RD offers a promising model for facilitating participation in AMR mitigation plan. However, the differences in policy uptake in both countries highlight the limits of participatory approaches when not aligned with policy scale and resourcing.