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A Theory of Change (TOC) is the foundation for any mission-driven initiative. Most often, it is used to show the logical relationship and chronological flow between actions and outcomes that lead to the desired impact. The value of a TOC is that it fosters accountability and awareness about the potential challenges that might be faced by key stakeholders.

Before building our TOC, the Fox Family Foundation team thought carefully about a single question:

How do we break the link between poverty and vision loss?

Vision loss and its link to poverty has been researched extensively. Both nationally and globally, vision impairment and blindness are more prevalent in less affluent communities, and low-income and minority children are disproportionately likely to have unmet vision-care needs.

Low vision disorders can significantly impact a person’s independence, well-being and quality of life, and can make everyday activities seem impossible. In all, more than 7 million people in the United States are living with a vision impairment, including more than 1 million Americans who are living with blindness. Another 48-million Americans are affected by refractive error that can be treated with glasses or contact lenses, but almost 33% of these cases go undiagnosed or otherwise uncorrected. According to the American Vision Council, up to 80% of cases dealing with visual impairment are considered preventable.

While the majority of Americans experiencing low vision are ages 40 years and older, 6.8% of children younger than 18 have a diagnosed eye and vision condition. Of those, nearly 3% will be legally blind or visually impaired (BVI) -- defined as having trouble seeing even when wearing glasses or contact lenses.

Being a member of a family that lives below the federal poverty line nearly doubles the likelihood that a child will be visually impaired as compared with children from families whose income is greater. Though BVI can be a severe disabling condition, the expected incidence rate is less than 1% of total statewide enrollment in special education. As a result, there is less funding and interventions addressing the social, educational and workforce challenges BVI populations face. Yet, the number of blind and visually impaired people is expected to double by the year 2050 and the number of preschool children with visual impairments is expected to increase by 26% by the year 2060.

The annual economic burden of vision loss amounted to $172-billion in 2020 for all Americans -- of which $10-billion was spent on children who do not receive the proper vision screenings and follow-up care. According to national forecasts, expenditures of vision problems will reach $385-billion by 2032 and $717-billion by 2050.

More pressing are the personal costs. Of the half-million plus blind, low-vision, and vision-impaired students enrolled in American K-12 schools, historically only 31% will earn a high school diploma, 30% will have an associates degree or some college, and 15% will have a bachelor’s degree or higher. As a result, people with vision loss ages 16-64 hover at a 39% labor force participation rate (61% not in the labor force) and a 10% unemployment rate.

For people with visual disabilities, work remains the best route to independence and mental wellness. Assistive Technology (AT) is often crucial in removing barriers to employment, so long as the prospective employer has the confidence to hire a BVI candidate. Most employers have limited or no knowledge about how blind or visually impaired persons perform routine job tasks. Negative employer perceptions about BVI people remains one of the most common barriers to their employment.

While schools must provide and pay for assistive technology, the more impoverished schools can’t always supply high-tech AT devices due to lack of funds, device unavailability, or the incapacity of device use at the student’s home due to broadband issues. This is a glaring inequity for low-income disabled children. About four-in-ten adults with lower incomes do not have home broadband services (43%) or a desktop or laptop computer (41%), thereby limiting the usefulness of many AT tools outside of school. Further, unless teachers adapt the general curriculum using assistive technology, students with severe vision disabilities will not be given the opportunity to participate equally.

Scientific literature suggests that although individuals with disabilities of all ages have personal experience with AT, they tend to lack sufficient skills and knowledge to effectively participate in the digital society, which widens the socioeconomic digital divide. Compounding this issue, special education students across the country report low academic expectations in their school, regardless of their actual ability-level or future plans.

The shortage of competent Special Education teachers, Teachers of students with Visual Impairments (TVI) and other trained experts who specialize in working with BVI individuals also exacerbates the problem. While over 80% of BVI students are in traditional classrooms, it's estimated that only 13% of US blind students are Braille readers -- an important literacy skill that has been linked with employment gains and higher levels of confidence.

The U.S. Department of Education has acknowledged the shortage of Special Education teachers by offering incentives. But even with a federally funded program that offers a yearly living stipend, covers the cost of graduate school tuition and fees, too few will certify as TVI teachers. As with other workforce shortages, awareness of these jobs is one of the factors deserving of intervention.

Similarly, the lack of a trained eye-care workforce negatively impacts low-income community members. Public health evidence reveals that access to care improves when the physician community reflects the population at large. Although underrepresented minority (URM) groups comprise 30.7% of the U.S. population, they only make up 6% of practicing ophthalmologists. Moreover, the Bureau of Labor Statistics projects there won’t be enough ophthalmic doctors and allied ophthalmic professionals to care for the growing numbers of patients in the years ahead.

When URMs graduate from medical training, they most frequently return to their own communities to practice. This is important because compared with older White Americans, Black and LatinX people have higher risks of progressing from mild to severe disability and experience more adverse disability trajectories. Embracing diversity, equity, and inclusion not only bridges cultural expectations, it also assists with language barriers.


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