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BACKGROUND While e-commerce is well established in several markets, adoption of online pharmacies has been slow. One reason for this could be that customers perceive risks when buying medicines online. The perception of risk may be due to the type of product (over-the-counter or prescription drug), but also to the website of the online pharmacy. Website acceptance is significantly influenced by risk and trust perceptions, and the effects of emotions on risky decisions form the basis for behavioral intentions toward onine pharmacies. OBJECTIVE The objective of this study is to understand the purchasing experiences of online pharmacy customers in terms of critical factors for online pharmacy adoption. This study examines the emotions, perceived risk, and perceived trust of purchasing medications online and, consequently, purchase intention toward the online pharmacy. METHODS In a within-subjects design (37 participants), two German online pharmacies with different perceptions of risk and trust for the main business of pharmacies, namely over-the-counter and prescription drugs, are investigated. Emotions are measured with a multi-method approach during and after the purchase situation as follows: 1) the neural evaluation processes using functional near-infrared spectroscopy (fNIRS), 2) the automated direct motor response during the use of the online pharmacy using facial expression analysis (FaceReader), and 3) the subjective evaluations through self-reports. RESULTS The online pharmacy with the higher perceived risk and lower perceived trust scored higher for negative emotions in the self-reports on emotions. The intention to shop at this pharmacy is also significantly lower. Purchasing prescription medication in the higher risk pharmacy resulted in significantly stronger negative emotional expressions on the customers' faces, and neural activation in the vmPFC; both of which may relate to perceived loss. CONCLUSIONS A higher perceived risk is reflected in the customer's face as a significant negative emotional reaction. Through multi-method measurements, we were able to show that the preceding neural activation and subsequent verbal evaluation of online pharmacies are reflected in the immediate emotional facial expression. When purchasing from the riskier online pharmacy for prescription drugs, the strongest negative emotions are measured on the customers' faces. Especially for prescription products, online pharmacies need to reduce the perception of risk, e.g., through trust-building design elements on the website, in order to increase the purchase intention. CLINICALTRIAL University of Duisburg-Essen (21-9995-BO).

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