It is challenging to change physicians' antimicrobial prescribing behaviour. Although antimicrobial prescribing is determined by contextual (e.g. a lack of guidelines), cultural (e.g. peer practice) and behavioural (e.g. perceived decision making autonomy) factors, most antimicrobial stewardship programmes fail to consider these factors in their approach. This may lead to suboptimal intervention effectiveness. We present a new approach in antimicrobial stewardship programme development that addresses relevant determinants of antimicrobial prescribing: participatory action research (PAR). PAR is a collaborative process that aims to bring about change in social situations by producing practical knowledge that is useful in local practice. It requires substantial involvement of relevant stakeholders to address determinants of the studied behaviour and to facilitate empowerment. PAR is well suited for complex problems in multidisciplinary settings as it adapts to local needs, delivering a tailored approach to improving local practice. We describe how PAR can be applied to antimicrobial stewardship, and describe the PAR design of two ongoing multicentre antimicrobial stewardship projects, in the acute care setting and the long-term care setting, respectively. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.