Milk consumers in Pakistan and Italy: a comparative study on the effects of geographical affiliation, socio-demographic characteristics and consumption patterns on knowledge, attitude and perception of antimicrobial resistance.

Antimicrobials are extensively used in livestock to treat common diseases, including mastitis and other bacterial infections, with around 80% of food-producing animals receiving such treatments. Despite a ban in the EU since 2006, antibiotics are still used globally for growth promotion, exacerbating antimicrobial resistance (AMR). From the consumers' point of view, the potential exposure to resistant zoonotic bacteria in animal-derived food products may represent a threat to public health. However, consumers' knowledge and attitude vary across socio-demographic characteristics and geographical location. This study aims to evaluate the knowledge, attitudes, and perceptions (KAP) of milk consumers regarding AMR in Pakistan (as a representative of low-to-middle income countries (LMICs)), compared to Italy (as a representative of high-income countries (HICs)).Data were collected via surveys from 401 Pakistani and 550 Italian milk consumers, focusing on socio-demographics, milk purchasing habits, and awareness of antibiotic residues and AMR. The study identified three principal components (PCs) influencing milk consumption: milk quality attributes and tradition, family-dependence, and eating style-dependence. A cluster analysis categorized consumers into four groups: "Attentive to milk quality attributes," "Loyal to milk," "Undecided consumer," and "Milk is essential in my food pattern."Italian consumers predominantly belonged to the "Attentive to milk quality attributes" group, valuing safety and health benefits, and were the most informed about AMR. Pakistani consumers, primarily belonging to the "Loyal to milk" group, exhibited high purchasing frequency influenced by family size but showed limited awareness about AMR risks. The "Undecided consumer" group, a mix of Italian and Pakistani individuals, lacked strong preferences and displayed moderate awareness of AMR, influenced by habitual consumption patterns.This research underscores the need for targeted educational campaigns to raise awareness about AMR and antibiotic residues in milk, particularly in LMICs. Survey findings can help to identify targeted action plans and boost policy development on AMR. Enhancing consumer knowledge through the One-Health approach could mitigate AMR risks and promote informed decision-making in milk consumption across different socio-economic contexts.